A Deadline Whizzes By and Indian Health Money Is Left Behind

Monday was a key deadline for the Affordable Care Act. In order to begin insurance coverage on January 1, 2014, people were supposed to sign up by December 23, 2013, for that shiny new policy.

(On Monday the White House announced the deadline is extended a stay. That’s a good thing for people trying to navigate the web site at the last minute.)

How many American Indians and Alaska Natives signed up for this new program? Who knows? But you’d think that something this important would have so much information posted about it that it would almost be annoying. There should be posters, flyers, signup fairs, reminders and banners. This should be a big deal.

Instead this deadline whizzed by, hardly making a sound in Indian country.

But this is why the deadline – and health insurance matters. From this point forward every American Indian and Alaska Native who signs up for some form of insurance, through a tribe or an employer, via Medicaid, or through these new Marketplace Exchanges, adds real money to the Indian health system.

How much funding? Healthcare reform expert Ed Fox estimates the total could exceed $2 billion. But what makes that $2 billion even more important is that it does not need to be appropriated by Congress.

Most of that funding stream will come from the expansion of Medicaid, the primary mechanism for expanding coverage under the Affordable Care Act. This is a particularly thorny problem for Indian country because only about half of the states with significant American Indian and Alaska Native populations have expanded Medicaid. That’s why it so important for Indian country to keep pressing for this critical funding source.

But even without the Medicaid expansion, many in Indian country are eligible for special considerations through the Marketplace exchanges. Most people won’t have to pay out-of-pocket costs like deductibles, copayments, and coinsurance depending on income. And American Indians and Alaska Natives have a sort of permanent open enrollment period, so the signup can occur anytime.

But, as Dr. Fox writes, “Unfortunately, fewer than 10 percent of those American Indians/Alaska Natives eligible for subsidies will purchase qualified health plans, even fewer American Indians/Alaska Natives likely if they currently receive services at an IHS-funded health program.”

So the problem remains that as long as one-in-three (non-elderly) American Indians and Alaska Natives are uninsured, there will not be enough money to pay for quality healthcare.

But the Affordable Care Act is an alternative. This is the deal: The Indian health system has never been fully funded. And that is not likely to change in our lifetime. No Congress or president in the history of this country has ever presented a budget that meets the health care needs of Indian country.

But the Affordable Care Act opens up a new way of tapping money, exchanging complexity and paperwork for more money that does not have to go through Congress. Money that can go directly and automatically into the Indian health system. According to the Kaiser Family Foundation, nine in ten American Indians and Alaska Natives qualify for some sort of assistance to get coverage.

The Affordable Care Act’s potential revenue stream is particularly important right now because the appropriations process in Congress is so completely broken.

But. Wait! American Indians and Alaska Natives have a treaty right to health care. There is no need to do anything, right?

Then I was re-reading my tribe’s treaty with the United States, the Fort Bridger Treaty of 1868. Article 10 says: “The United States hereby agrees to furnish annually to the Indians the physician, teachers, carpenter, miller, engineer, farmer, and blacksmith, as herein contemplated, and that such appropriations shall be made, from time to time, on the estimates of the Secretary of the Interior, as will be sufficient to employ such persons.”

And there is that word: “appropriations.” The process that Congress uses to spend money; a framework that has never even once considered full funding for Indian health.

I hear from many folks who say this is all too much. Let’s repeal the law and start over. Ok, then what? Repealing the law is not going to change the dismal funding of the Indian health system. Congress cannot even agree on regular spending, let alone something like that. But for all the complications, for all the confusion about web sites and paperwork, the Affordable Care Act opens up a check book with a couple billion dollars. We can watch deadlines whiz by. Or, we can say, there it is. Take it.

Mark Trahant is the 20th Atwood Chair at the University of Alaska Anchorage. He is a journalist, speaker and Twitter poet and is a member of The Shoshone-Bannock Tribes. Join the discussion about austerity. Comment on Facebook at: www.facebook.com/TrahantReports.